u n i v e r s i t Ä t s m e d i z i n b e r l i n
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U N I V E R S I T Ä T S M E D I Z I N B E R L I N. Pneu Concepts in Pneumothorax. Tobias Lindner Emergency Dpt.- Trauma Wing. Diagnostics ….. WHAT DO WE HAVE ?. clinicial examination chest film ultrasound CT. Diagnostics ….. clinical examination. - PowerPoint PPT PresentationTRANSCRIPT
U N I V E R S I T Ä T S M E D I Z I N B E R L I NU N I V E R S I T Ä T S M E D I Z I N B E R L I N
Tobias Lindner
Emergency Dpt.- Trauma Wing
Pneu Concepts in Pneumothorax
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Diagnostics ….. WHAT DO WE HAVE ?
clinicial examination chest film ultrasound CT
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Diagnostics …..clinical examination auscultation alone is not reliable !
118 patients, penetrating chest injury
71 (60%) with Ptx
30 of these (42%) not diagnosed by inhospital auscultation !
(control: chest radiograph !) Chen et al. : Hemopneumothorax missed by auscultation in
penetrating chest injury. J Trauma. 1997
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Diagnostics ….. chest film……
….. there is a problem: occult pneumothorax
109 patients after chest trauma
only 13 of 25 PTXs detected by
supine ap chest film (control: CT)
sensitivity 52%, specifity 100 %
Soldati et al. : Occult traumatic pneumothorax: diagnostic accuracy of lung ultrasonography in the emergency department. Chest. 2008
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blunt chest trauma, cyclist hit by car
Diagnostics ….. chest film……
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blunt chest trauma, pedestrian hit by metal from lorry
Diagnostics ….. chest film……
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Diagnostics ….. ultrasound…….
Ouellet J-F et al., The sonographic diagnosis of pneumothorax. J
Emerg Trauma Shock. 2011Stone MB et al., The heart point sign: description of a new ultrasound finding suggesting pneumothorax.Acad Emerg Med. 2010
seahore- sign
stratosphere- sign
M- mode, sliding lung sign
comet- trail- artifacts
reverberations
B- mode
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M- and B- mode, 3 min. per side, convex probe
operators at least 1 year experience (ER personnel)
23 of 25 PTXs detected by ultrasound (remember: only 13 by ap chest film !)
92 % sensitivity, 99.4 % specifity, NPV 98,9
Soldati et al. , Occult traumatic pneumothorax: diagnostic accuracy of lung ultrasonography in the emergency department. Chest. 2008
Diagnostics ….. ultrasound…….
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evidence based review (chest ap radiograph vs US)
4 prospective studies, gold standard: CT
606 patients, blunt trauma cases
US: sensitivity 86- 98 %, specifity 97- 100 %
chest ap supine: sensitivity 28-75 %, specifity 100 %
RG Wilkerson et al., Sensitivity of Bedside Ultrasound and Supine Anteroposterior Chest Radiographs for the Identification of Pneumothorax After Blunt Trauma. Acad Emerg Med.. 2010
Diagnostics ….. ultrasound……
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20 studies, US: pooled sensitivity/ specifity = 88/ 99 % (CR: pooled sensitivity/ specifity = 52/ 100 %) bedside US performed by clinicians had higher
sensitivity and similar specificity compared to CR US depended on the skill of the operators US is reliable & advantage of portability, rapidity and
non biological invasive
Diagnostics ….. ultrasound……
Ding et al., CHEST. 2011
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however……….
does not favor ultrasound in diagnosing spontaneous PTX – results too conflicting
(for them !)
Diagnostics …..
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......instead: standard erect chest x- ray in inspiration (SP)
lateral views might be helpful, but no routine
expiratory films without additional benefit
in doubt : CT
Diagnostics …..
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Therapy…..Guidelines ?
Primary & Secondary Spontaneous Pneumothorax
(PSP/SSP)
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2001
2010
&
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Therapy……PSP (small, stable)
small* vs large stable** vs unstable
*apex/ cupula distance < 3cm on chest film**resp. rate < 24/ min., hr
> 60/ min. and < 120 /min., bp normal, O2 sat. room air > 92 %
small* vs large clinical compromise breathlessness ? **
*hilum to lateral chest wall < 2 cm on chest film
**not definded
observation in ER for 3-6 hrs.check x- rayDISCHARGE (if unchanged)
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Therapy…..PSP (large, stable/unstable)
stable & large: small- bore catheter
(< 14 F) or chest tube (16-22F)
discharge possible with Heimlich valve
unstable & large: small- bore catheter
or chest tube admit !
>2cm &/or breathless: needle aspiration discharge after check x- ray
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stable, small: observation or tube fatal cases during
observation reported !!! (O´Rourke. Chest. 1989)
all others: chest tube
admit all !
Therapy…….SSP
only in < 1 cm without compr.:
consider observation or NA size 1-2 cm/ not
breathless: needle aspiration
2cm at level of hilum &/or breathless: small bore catheter
admit all !
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(needle aspiration) small- bore catheter (<
14F) chest tube (16- 28F)
needle aspiration 1st choice, unless:
bilateral PTX SSP and > 2cm at level of hilum on CR
small bore chest drains (8-14F) (generally, no need for larger bore catheters in all spontaneous PTX)
2001
2010
Bringing it together……
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NA vs Chest tube in PSP 1 included study, total of 60 patients 27 underwent simple aspiration 33 underwent intercostal tube drainage
no significant difference with regard to: immediate, one week or one year success rate
simple aspiration is associated with a reduction in hospitalization rate (53 vs 100 %)
Wakai et al., Simple aspiration versus intercostal tube drainage forprimary spontaneous pneumothorax in adults. Cochrane review.
2007.Based on: Noppen 2002
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review NA as safe and successful as tube thoracostomy fewer hospital admissions after NA shorter hospital stays (if admitted)
Zehtabchi et al., Management of Emergency Medicine Department Patients
With Primary Spontaneous Pneumothorax : Needle Apsiration or TubeThoracostomy ? Ann of Emerg. Med.. 2008.
review NA might fail in larger PTX also SSP studies included !
Chan et al. , The Role of Simple Aspiration in the Management of Primary
Spontaneous Pneumothorax, J of Emerg. Med., 2008.
NA vs Chest tube in PSP
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general remarks: supplementary O2 therapy (at least 24 h)
- increases resolution rate by reduction of nitrogen partial pressure
no flights until then plus 1 week, but:generally, recurrence risk drops sign. only after 1 year !
no diving unless bilateral pleurodesis !
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chest drain removal:
41 % of panel members do clamp all check CR before removal 63 % after 13-23hrs after last evidence
of air leak
clamping is generally unnecessary period without suction before
removal
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Traumatic PTX
general remarks:
2nd rank of injury after chest trauma (after rib fx)
relevant prehospital Dx !
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Diagnostics …..clinical examination
might be (more) reliable in trauma than in spontaneous Ptx
!
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Traumatic PTX- Diagnostics
synopsis of auscultation, respiratory rate /shortness of breath. diagnostic accuracy can be improved by combining these three signs…… (and putting hands on ! )
Waydhas et al.,Prehospital pleural decompression andchest tube placement after blunt trauma: A systematic review.Resuscitation. 2007.
……..but still: clinical examination is very variable…..
……. need of: safe, objective method independent from setting
German Guideline on Polytraumamanagement- Prehospital Section, 2010
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Diagnostics ….. ultrasound……
prehospital: possible as on scene method
but still
skill dependend !
Kirkpatrick et al. , Hand- Held Thoracic Sonography for Detecting Post- Traumatic Pneumothoraces: The Extended Focused Assessment With Sonography for Trauma. J of Trauma. 2004
Walcher et al., Optimierung desTraumamanagements durch präklinische Sonographie. Unfallchirurg. 2002
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Diagnostics …..what else is on the horizon ?
micropower impulsed radar/ultrashort radar pulse
spatial accuracy of approx. 5mm
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Diagnostics …..what else is on the horizon ?
portable/ point of care non- invasive easy 1-2 min. scan time skin contact unnecessary penetrate through clothing ? specific location and volume ?
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Diagnostics …..what else is on the horizon ?
promising !
easy, quick, repeatable, not this operator depended, objective !
INDEPENDENT from preclinical setting !
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Therapy –Traumatic PTX
should all be treated with chest drains !
air & blood ! 28- 36 F !
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Pneu Concepts in Pneumothorax
US is accepted (in experienced operators hands) for diagnosing PTX
needle aspiration is the evolving method of choice for active intervention in MOST spontaneous PTx !?
there is an urgent need for a easy & objective tool for PTX diagnostics in the prehospital setting !
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Danke !